The applicant Is a Research Associate at the Alzheimer's Disease and Memory Disorders Center at Rhode Island Hospital. Her extensive clinical background in geriatric psychopharmacology and nursing home medicine is the foundation for her long term goal to become an independent health services researcher. This proposal focuses on comparative effectiveness research in an oft neglected population - persons with dementia living in nursing homes. The research questions seek to investigate the cognitive, functional, and neurobehavioral outcomes associated with the use or discontinuation of certain psychoactive drugs in individuals with dementia and comorbid medical illness. The proposed training plan will develop additional skills through 1) coursework in epidemiology to expand methodologic and analytic skills, 2) interaction with the mentorship team, including experts in health services research and dementia research, and 3) completion of two observational pharmacoepidemiologic studies utilizing large automated cross-linked datasets. Findings from these studies will provide clinically relevant information to inform treatment of elderly patients with dementia; a population systematically excluded from clinical trials. Using state of the art methods for estimating treatment effects from non-experimental studies, the aims are 1) to evaluate the longitudinal behavioral, cognitive, and functional effects of discontinuing stable cholinesterase inhibitor (CHEI) therapy compared to continuous CHEI therapy in nursing facility residents with dementia, 2) to determine the extent to which cognitively impaired individuals who receive isoflurane general anesthesia during hip fracture repair experience greater post-operative cognitive and functional decline in the year after surgery compared to patients receiving other types of general anesthesia, and 3) to quantify the effects of isoflurane anesthesia vs. other general or regional (spinal or epidural) anesthesia on the rate of post- operative cognitive and functional decline in cognitively impaired patients in the year after hip fracture repair surgery.